Universal Assessment Tool

Bathing - the process of washing, rinsing and toweling the body or body parts and transferring in/out of the tub or shower. This includes the ability to get the bath water and/or equipment, whether this is in bed, tub, shower, or sink. Use of assistive devices such as tub/shower chair, pedal/knee controlled faucets, or long-handled brushes does not disqualify the client from being independent. If the client has a problem getting to and from the bathroom to bathe, that should be reflected in the Mobility section and should not affect the score for bathing.

Assessment Considerations:

1. When taking a bath/shower, can the person get their own towel, washcloth, soap, and run the water?
2. Can the person tell if the water is too hot or too cold?
3. Is the person able to get in and out of the shower or tub by themselves?
4. Does the person need a bath bench, shower seat or hand held shower to assist with bathing?
5. What kind of problems does the person have with bathing him/herself?

Minimum = the client requires up to minimal supervision, verbal cueing, assistance in and/or out of the shower, and may need assistance with washing back or lower extremities.

Moderate = the client requires step by step cueing with the entire bathing process, one person assist getting in and out of the tub/shower, and/or hands-on assistance with approximately 50% to 75% of the bathing process.

Maximum = the client is dependent on others for assistance with approximately 75% or more of the bathing process or requires assistance of two or more persons to get in and out of shower/tub or requires the use of a Hoyer lift.

Dressing - dressing includes laying out, putting on and fastening of clothing and footwear. Use of assistive devices such as reachers, sock pullers, shoe horns, Velcro fasteners does not disqualify the client from being independent.

Assessment Considerations:

1. Can the person choose their own clothes, get them from the closet or drawer, put them on and button the buttons, fasten/close the zipper or tie their shoes?
2. If someone lays out the clothes, can the person put them on?
3. Does the person have assistive devices to assist in dressing, such as reachers, sock pullers, shoe horns, Velcro fasteners?
4. How does the person get dressed if help is needed?

Minimum = the client may need some supervision or reminding (for example, laying out clothes, giving advice or being available.

Moderate = the client required hands-on physical assistance of another person or supervision with approximately 50% to 75% of the dressing activities.

Maximum = the client needs assistance with dressing approximately 75% or more of the time.

Grooming - grooming activities include combing hair, shaving, brushing teeth, washing hands/face, nail care and/or menses care. Obtaining the water and supplies necessary to complete the task are included in grooming.

Assessment Considerations:

1. Can the person run the sink water and wash their face, comb their hair and brush their teeth?

Minimum = the client needs up to minimal supervision or reminding (for example, setting up grooming implements, giving advice, being available, menses care).

Moderate = the client requires some physical assistance or supervision or step by step cueing with approximately 50% to 75% of their grooming activities.

Maximum = the client is dependent on others for assistance with approximately 75% or more of their grooming activities.

Eating/Feeding – the process of getting nourishment by any means from a receptacle (dish, plate, cup, glass, bottle, etc.) into the body. Use of mechanical aids such as modified utensils or plate guards does not disqualify the client from being independent.

Assessment considerations:

1. Can the person effectively get food and beverages into his/her mouth?
2. Can the person cut his/her own meat?
3. Does the person use any mechanical aids to assist with eating?
4. Is the person receiving an intravenous or tube feeding as a means of total nutrition?
5. Does the person need cueing or supervision to ensure an adequate intake?

Minimum = client requires some supervision, reminding, set-up or cutting, including alteration of food (for example, pureeing) or hands-on assistance with less than half of the meal task.

Moderate = client requires hands-on physical assistance, cueing or reminding with approximately 50% to 75% of the meal task, but can participate physically.

Maximum = client requires hands-on physical assistance with approximately 75% or more of the meal task or is totally dependent for nutritional needs (for example, tube feeding or TPN).

Mobility – the extent of the client’s purposeful movement within their residence. The use of assistive devices such as a wheelchair, walker or quad cane does not disqualify the person from being independent.

Assessment Considerations:

1. Can the person purposely move about in his/her current environment independently?
2. Does the person have an unstable gait or balance?
3. Could the person avoid an obstacle in his/her path?
4. Does the person use any assistive devices such as a cane, walker, wheelchair or handrails?
5. Is the person unsafe without the assistance of another person in ambulating?

Minimum = approximately 50% or less of the time the client requires supervision, standby or hands-on assistance by one person for safety, including adjustment of assistive devices or restraints.

Moderate = approximately 50% to 75% of the time the client requires supervision, standby assistance or hands-on assistance of one person, including adjustment of assistive devices or restraints.

Maximum = approximately 75% or more of the time the client requires hands-on assistance of one or more persons or may be totally dependent on others for mobility (for example, cannot self-propel wheelchair).

Transferring – the client’s ability to move horizontally and/or vertically between the bed, chair, wheelchair, commode, etc.

Assessment Considerations:

1. Can the person move horizontally or vertically between the bed, chair, wheelchair or commode independently?
2. Does the person display any weakness or unsteady balance, which would require assistance when transferring?
3. Does the person use any mechanical devices such as a walker, cane, handrails or wheelchair to assist with transfers?
4. Can the person physically participate in the transfer by pivoting, holding on, or bracing themselves to assist the caregiver?

Minimum = can transfer to some or all surfaces independently. If needed, the assistance of no more than one person to transfer from one surface to another with or without assistive devices. The client may require some supervision or reminding or standby assistance for safety.

Moderate = the client requires hands-on physical guidance or assistance of one person for all transfers. The client may participate by being able to bear weight and pivot.

Maximum = the client requires assistance of two or more people to be physically lifted or moved.

Continence – the ability to voluntarily control the discharge of body waste from bladder or bowel. Incontinence means the involuntary loss of bowel and bladder contents. Stress incontinence means the inability to prevent escape of small amounts of bowel/bladder contents during certain activities such as coughing, lifting or laughing.

Those who willfully toilet in inappropriate places will not necessarily be assessed as being incontinent. These behaviors may be assessed in other parts of this instrument (for example, Behaviors). Those who receive dialysis and do not urinate will be rated as continent of bladder.

Clients who have no voluntary control secondary to physiological conditions and rely upon dilatation, indwelling catheters, intermittent catheterization, ostomies, condom catheters or placed urinals for evacuation should be rated as totally incontinent in the applicable function.

Bladder Continence – the ability of the client to voluntarily control the discharge of body wastes from the bladder. A client with a Foley catheter or ostomy will be scored maximum.

Assessment Considerations:

1. Does the person have any episodes of incontinence?
2. Can the person “hold their urine” until they get to the toilet?
3. Does the person have accidents when they sneeze or cough?
4. How frequently does the person have accidents – once or twice a week, every day, once a month?

Minimum = the client may be incontinent less than seven times a week.

Moderate = the client may be frequently incontinent or incontinent daily, but some control is present (for example, daytime, or if toileted frequently).

Maximum = the client is totally incontinent of bladder, receives scheduled toileting on daily basis to avoid bladder incontinence and/or receives care of a catheter or ostomy.

Bowel Continence - the ability of the client to voluntarily control the discharge of body wastes from the bowel. A client with an ostomy will be scored maximum. Assessment Considerations:

1. Does the person have bowel accidents?
2. Does the person ever soil their clothing?
3. How often does the person accidents?

Minimum = the client may be continent less than seven times per week.

Moderate = the client may be frequently incontinent (seven times or more per week) or incontinent daily, but some control is present.

Maximum = the client has no voluntary control of bowel and/or receives care of an ostomy.

Behavior – identify the presence of certain behaviors that may reflect the level of an individual’s emotional functioning and need for intervention. Behaviors should be assessed based on the last 90 days (with particular attention to the past 30 days), or since the last review. Documentation should include frequency and type of behavior and if there has been or will be a request for mental health services.

Wandering is defined as moving about with no rational purpose and with a tendency to go beyond physical parameters of the environment in a manner that may jeopardize safety of self or others.

Repeated behaviors that cause injury to self (for example, biting scratching, picking behaviors; putting inappropriate objects into the ear, mouth or nose; head slapping or banging) or others (for example, physically attacking another person, throwing objects, punching, biting, pushing, pinching, pulling hair and physically threatening behavior).

Other repeated behaviors that interferes with the activities of others or the individuals own activities: for example, putting on or removing clothes inappropriately, stubbornness, sexual behavior inappropriate to time, place or person, excessive crying or screaming, persistent pestering or teasing; constantly demanding attention and urinating or defecating in inappropriate places, or threats and or attempts to take one’s own life.

Minimum = requires staff intervention less than 50% of the time for episodes of confusion, memory defects, impaired judgment, or agitation. May require temporary (24 hours or less) restraints to control a behavioral or medical problem and restraints for personal safety.

Moderate = requires staff intervention approximately 50% to 75% of the time for episodes of confusion, memory defects, impaired judgment, or agitation. May have periodic emotional or mental disturbances, including combativeness.

Maximum = requires staff intervention approximately 75% or more of the time. May be disoriented, confused, combative, withdrawn, or depressed. May need restraints (physical/chemical) for personal safety or protection of others.

Medical Condition – refers to the degree of stability of health care needs that may require nursing and/or medical monitoring of treatment(s) and/or therapy to restore and/or maintain function. This does not include maintenance regimens (monthly weights and blood pressure checks).

Minimum = stable, with routine nursing/medical monitoring and care.

Moderate = conditions require more frequent professional monitoring to maintain stability (for example, unstable hypertension needing frequent assessment and medication adjustment).

Maximum = conditions require intense professional intervention to maintain stability (for example, unstable diabetes, coma, terminal medical conditions).

Medical/Nursing Treatments – refers to level of nursing and/or medical care that is required to perform medical assistance and interventions with current health care needs.

Minimum = Routine treatments, such as range of motion and injections, as well as routine medication administration and routine catheter care. Anything more would be considered at least “moderate”.

Moderate = Skilled nursing treatment in addition to routine medication administration (for example, treatment of stage one to three pressure ulcer, tube feeding).

Maximum = Relatively complex, with more than one professional or technical treatment, such as IV therapy, tube or parenteral feeding, care of recent wound, care of infected or stage 4 pressure ulcer, deep suctioning or an extensive rehab regimen.